Mental Health and Civil Liberties
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    A theoretical contrast of Thomas Szasz, Anthony Clare and Peter Sedgwick
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    Lecture Notes, Andrew Roberts, Autumn 1996

    Introduction: Compulsion and psychiatry
    William Blackstone: Compulsion pre-dates psychiatry
    Szasz, The Myth of Mental Illness
    Szasz's case against compulsion
    Szasz and dehumanisation
    Anthony Clare's defence of compulsion
    Anti-Psychiatry
    Peter Sedgwick's Psychopolitics

    INTRODUCTION: COMPULSION AND PSYCHIATRY

    You can receive treatment for mental illness from your own doctor or in a hospital, just as you would for physical illness. There is an important legal distinction, however. You cannot, generally, be treated for physical illness against your will, but you can for mental illness. In this country about one in ten admissions to mental hospitals are compulsory. In other countries the percentage is usually greater. Because of these compulsory powers, psychiatry has been criticised for undermining civil liberties.

    The movement critical of these powers has sometimes been called anti- psychiatry. Many of the concepts that it uses are taken from the work of Thomas Szasz, an American psychiatrist who has argued since the 1950s that compulsory psychiatry is incompatible with a free society. In this paper I outline the case against compulsion made by Szasz; the defence of compulsion made by an English psychiatrist, Anthony Clare; and the criticisms of Szasz and the anti-psychiatry movement made by Peter Sedgwick in his book PsychoPolitics. The object of the paper is not to argue a case, but to outline some of the theoretical concepts that I think are useful for analysing the issues.

    William Blackstone: Compulsion pre-dates psychiatry

    It would not be fair to blame psychiatry for the invention of compulsion. Psychiatry only gained the major responsibility for controlling madness in the 19th century, and society required madness to be controlled long before that. Statutes allowing magistrates to detain mad people were passed early in the 18th century - But, before that they could be detained under the common law. William Blackstone (1723-1780) in his Commentaries on the Laws of England, wrote that:

    "It was the doctrine of our ancient law, that persons deprived of their reason might be confined till they recovered their senses."

    There are two long established reasons for the legitimate use of compulsion against mad people:

    1. the protection of society

    2. compassion for the mad person.

    Blackstone said madmen should not be allowed out to the terror of the king's subjects. It seems, therefore, that his main concern was to protect society.

    Some examples of madmen being confined for their own good from the 17th century will be found in Hunter and Macalpine's collection of historical documents Three Hundred Years of Psychiatry. They quote the case of a man in 1654 who had fallen into a sullen, sad, melancholie and would not go indoors or eat or wash himself. His neighbours discovered that his head had become infested with maggots and decided something had to be done to help him. They forced him into a house and paid a women to dresse and take care of him. The local magistrates ordered that the costs should be paid from public funds. ( Hunter and Macalpine 1963 p.140)

    SZASZ, THE MYTH OF MENTAL ILLNESS

    Thomas Szasz (1920-) called his most famous book: The Myth of Mental Illness. By Myth he does not mean that psychological disorders are not real experiences. He means that to call them illnesses is misleading because they share little in common with physical illness. Szasz says that psychological disorders have only one significant characteristic in common with bodily diseases. This is that the sufferer is to some extent disabled from performing some activities. (See his discussion of the two classes of disability. Szasz 1961/1972 p.54)

    Psychological and bodily disorders differ, he says, in that psychological disorders can only be understood if they are viewed as things that do not just happen to a person, but are brought about by him: `Mental illness' is not something a person has, it is something he does or is (Szasz 1972/Summary). Psychological disorders are actions rather than events and they are of some value to the patient. The patient, however, is not malingering. He is not fully aware of what he is doing and it is the psychiatrist's job to help him find out. Physical illnesses, on the other hand, just happen to a patient, and cannot be cured by self-knowledge. You have to kill the bug, set the bone, or whatever.

    Szasz has attempted to replace the illness model of mental disturbances with an analysis in terms of meaningful (but perhaps unconscious) communication. Hysteria, for example, is a psychological disorder that manifests itself as physical illness. Szasz describes it as a dramatised representation of the message My body is not functioning well. The mental illness called depression is a dramatisation of the proposition I am unhappy. (Szasz 1961/1972 p.202)

    SZASZ'S CASE AGAINST COMPULSION

    Szasz regards the medical model of mental illness as an ideological justification for coercion. It is a way of excusing violence against mental patients by representing it as treatment. Szasz says that compulsory psychiatry cannot be justified medically or morally. It is a crime against humanity (Szasz 1972/Summary), and it undermines a free society.
    I said earlier that there are two established reasons for the use of compulsion, one of which is to help the patient. Szasz insists that one should not force help on anyone. In support of his case he quotes the philosopher, John Stuart Mill. Mill wrote:

    "The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral, is not sufficient warranty." (Mill 1859, quoted Szasz 1971, pp 349-340. Click on the quotation to read what Mill wrote in its context)

    Mill made an exception for those without the full use of their reason. Szasz does not.

    According to Szasz, it is a precondition of a free society that we do not force help on one another. We must be free to make our own choices and decide what is in our own best interest. In a society pledged to the advancement of individual freedom and responsibility, the State, the family and the medical profession must restrict themselves to offering help. (Szasz, T. 1978). He goes on to say that the law should prevent them forcing help on unwilling people.

    Szasz does not say that compulsory psychiatry is always harmful to the patient. His basic case is that it is incompatible with a free society. He says, in fact, that some increase in liberty gained by outlawing compulsion, might be at the cost of the impaired health or even death of some people who, he says, make themselves ill, or who want to kill themselves. Szasz says, that Freedom, entails the right to make the 'wrong' choice. (Szasz, T. 1978)

    SZASZ AND DEHUMANISATION

    As well as arguing that people should not be forcibly treated for their own good, Szasz argues that they should only be prevented from harming others by the process of law common to all of us: There should not be one law for the mentally ill and another for the sane.

    Szasz argues that to treat someone as less than responsible for their own actions is to treat them as less than fully human:

    To the extent that a person acts involuntarily, he cannot be regarded, in the social sense of the term, as a human being. (Szasz 1963, quoted Clare 1978 and Clare 1980 pp 357-358)

    This, he says leads to a dilemma in court cases, because when we regard an offender as insane and officially excuse him of his crime, we still punish him by treating him as someone less than human. The solution, for Szasz, is to treat all offenders as sane and punish them in the normal way. Anthony Clare says he cannot understand why someone who acts involuntarily has to be regarded as any less than human. Many patients do experience the process of being treated as mentally ill as a dehumanising one. but is it a logical necessity that it has to be so, as Szasz suggests?

    ANTHONY CLARE'S DEFENCE OF COMPULSION

    Anthony Clare, as well as being the star of In the Psychiatrist's Chair (A BBC programme), is the author of Psychiatry in Dissent. In this he defended compulsion, against the criticisms made by Szasz. I want to illustrate his case by looking at what he and Szasz say about the issue of suicide.

    Psychiatry is only relevant to suicide if mental disturbance led the victim to take his own life. An empirical study cited by Clare suggests this is often the case. In this: 93% of the suicides studied were said to have been obviously mentally disturbed at the time and 83% to have suffered from morbid depression or alcoholism (Clare, A. 1980 p.348)

    Szasz argues that people who want to commit suicide should be allowed to, even if they are mentally disturbed. He would help a patient sort out the issues in his mind, but he would not stop him killing himself.

    Clare suggests that Szasz's portrayal of suicide as a clear-cut and free decision is simplistic and even irresponsible. The study Clare cites suggests that most successful suicides were seeking help at about the time of their suicide. 80% had seen a doctor not long before and about the same proportion were taking drugs for psychiatric problems. Well over 50% had given reasonably clear warnings of their suicidal thinking. Clare describes the motivation of people who attempt suicide as bewilderingly complex: No one can ever say with certainty whether the failed suicide really wanted to die or live, the successful one to live or die. (Clare, A. 1980 p.351)

    Clare says that he would not confine every patient with suicidal thoughts to hospital. The decision would rest, amongst other thing, on the question of choice. In certain circumstances he would judge that a psychiatric patient's ability to chose freely was gravely compromised by his mental state. (Clare 1978)

    ANTI-PSYCHIATRY

    The 1959 Mental Health Act has been described as a psychiatrist's Act because it removed controls on admissions and treatment. The Act relied on psychiatrists acting in the best interests of their patients. At the time it was passed, many progressively minded people were working to remove the stigma from mental illness. Psychiatry had a liberal image and was associated with this endeavour. Consequently, organisation like the National Association for Mental Health (now Mind) tried to remove the public's fear of mental hospitals and encouraged people to seek psychiatric help.

    During the 1960s the liberal image of psychiatry began to crack up. By the 1970s there were many movements and theories critical of psychiatry. People tried to sum these up in the catch-all phrase "Anti-psychiatry". Anti-psychiatry was generally considered radical, whereas psychiatry was, at best, a bit "old-hat". It can be argued that the 1983 Mental Health Act was, in some ways, one of the achievements of this anti-psychiatric phraseşBecause of the controls it places on treatments.

    PETER SEDGWICK'S PSYCHOPOLITICS

    Peter Sedgwick ( -1983) was a left wing writer who argued that anti- psychiatry diverted people from more important issues. Sedgwick described himself as a revolutionary socialist. His book, PsychoPolitics, was published in 1982. It contains detailed critiques of four libertarian writers whose work was influential in creating the anti-psychiatric tone of radical literature in the 1970s. The four authors are: Thomas Szasz (who we have already discussed), Erving Goffman (who wrote Asylums), a psychiatrist, Ronald Laing and a historian, Michel Foucault. The gist of Sedgwick's complaint against these four authors is that their anti- psychiatric concern has stifled the development of a political alliance for better services for mentally ill people. I am only going to look at what Sedgwick has to say about Szasz.

    SEDGWICK AND THE CONCEPT MENTAL ILLNESS

    Sedgwick does not agree with Szasz's radical separation of mental disturbances and physical illnesses. Szasz thinks mental illness is socially constructed, but physical illness is natural. Sedgwick argues that both are socially constructed. (Sedgwick 1982 p.29). He believes that society can decide to include in the category illness, whatever it likes. Medical technology, he writes, has succeeded in classifying illnesses as particular states of the body only. But he says this link of illness with physical damage is not essential.

    Both Szasz and Sedgwick agree that mental illness is disabling. And it seems that Sedgwick would like society to make disability the factor that decides if something is an illness. I pointed out earlier that disability is the one thing Szasz thinks mental and physical illness have in common. The reason that Sedgwick is so anxious for mental disabilities to be called illnesses is political: Without the concept of mental illness, he argues we shall be unable to make demands on the health service facilities of the society we live in (Sedgwick 1982 p.40).

    SEDGWICK: POSITIVE, NOT CONTRACTUAL AND LEGAL FREEDOMS

    I now turn to what Sedgwick has to say about the case against compulsory psychiatry. He says that Szasz is concerned with contractual and legal freedoms at the expense of positive freedoms. Let us look at these one at a time:

    CONTRACTUAL FREEDOM: Sedgwick describes Szasz's ideal of contractual freedom as the freedom to pay up or perish (Sedgwick 1982 p.179). It is the freedom to pay up because Szasz is an advocate of private psychiatry for which the patient pays. The contract is the contract between the psychiatrist and his patient to deliver therapy in exchange for cash. Szasz depicts public health provision as necessarily coercive. So he wants to replace it by a fee-paid two-person psychotherapy in order to maintain the patient's control over the situation (Sedgwick 1982 p.154). But, as Sedgwick points out, this would be of no value to poor or chronically disabled people. The poor could not afford it and psychotherapy is not what chronically ill people need.

    Sedgwick also points out that the picture of public provision as coercive does not fit the situation in this country where involuntary hospitalisation is a minority procedure. Even in America, he says, it is of decreasing importance. (Sedgwick 1982 p.153)

    LEGAL FREEDOM: Szasz wants the law to stop psychiatrists forcing help on unwilling people. Sedgwick concentrates on two aspects of this position. First Szasz's belief that people should be allowed to commit suicide, and second, his similar belief that drug addicts should be free to destroy themselves with drugs if they chose to. These beliefs, according to Sedgwick, reflect an individualisation of social problems. You may have heard the following quotation from a sermon by John Donne (1572-1631): any man's death diminishes me, because I am involved in mankind. Sedgwick says this is a higher statement of ethics than Szasz's laissez faire attitude (Sedgwick 1982 p.165). His implication would seem to be that we have both a duty and a personal interest in intervening to prevent people destroying themselves.

    Sedgwick quotes a newspaper report that tens of thousands of patients in the USA have been released as a result of court cases over the last ten years. This is legal freedom, but what value is it? Hospitals have been shut but there has been nowhere for the patients to go. As a result some ex-patients have ended up in prison. Others are exploited by private landlords. Some were re-admitted to other mental hospitals and some had just died. (Sedgwick 1982 pp.216-217).

    POSITIVE FREEDOM: Positive freedom is the concept of freedom that Sedgwick considers superior to Szasz's contractual and legal freedoms. The ideal of positive freedom, he says, is to maximise the power of all members of society alike to make the best of themselves. He says we should not be arguing over which sort of suicidal patients should be let looseşto go and kill themselves (Sedgwick 1982 p.179). Instead we should be providing community facilities to allow mental patients to live positive lives outside mental hospitals.

    So: positive freedoms are those that alow people to live positive lives. You should notice that Sedgwick's version of freedom involves public expenditure. I recall Linda Chalker telling a MIND conference that a Conservative Government might well favour more rights for mental patients as it was a reform that would not cost much money. Her idea of freedom, on this occasion, was more like Szasz's than Sedgwick's.

    Sedgwick thinks the anti-psychiatrists were wrong to put their efforts into arguing a civil liberties case when the important issue is community care. To secure meaningful freedoms he thinks we should be re-organising our social life to provide what he calls substitute family units for mentally ill people. These would allow them to live in the heart of the community and so permit the closure of mental hospitals without causing the distress to ex-patients that the American report spoke of.

    Bibliography

    Clare, A.W. 1978 In Defence of Compulsory Psychiatric Intervention The Lancet 3.6.1978
    Clare, A.W 1980 (2nd edition) Psychiatry in Dissent. Controversial Issues in Thought and Practice.
    Hunter, R.A. and Macalpine, I. 1963 Three Hundred Years of Psychiatry 1535-1860
    Mill, J.S. 1859 On Liberty
    Sedgwick, P. 1982 PsychoPolitics.
    Szasz, T. 1961/1972 The Myth of Mental Illness. Foundations of a Theory of Personal Conduct. (Paladin edition, abbreviated with a summary, 1972*)
    Szasz, T. 1963 Law, Liberty and Psychiatry
    Szasz, T. 1971 The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement.
    Szasz, T. 1978 The Case Against Compulsory Psychiatric Interventions
    The Lancet 13.5.1978

    © Andrew Roberts 9.1996-


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